The tip of the iceberg

While the rate of teenage pregnancy is creeping down, figures for STIs are moving in the opposite direction - rapidly. Cases of syphilis and gonorrhoea in the under-20s have more than doubled since 1995, while incidences of chlamydia have tripled to around 20,000 a year. In the National Chlamydia Screening Programme in 2003-04, 10 per cent of young men and over 12 per cent of young women in the 16-19 age group tested positive.

The number of 16-19 year olds seen at genito-urinary medicine (GUM) clinics in the UK rose from just under 37,000 in 2000, to over 50,000 in 2004.

Not only are these figures still rising, but it’s likely that they represent the tip of a pretty substantial iceberg. While statistics are gathered from GUM clinics, young people seeking help from youth services or family planning clinics simply don’t show up. And plenty of embarrassed teenagers don’t come forward at all, meaning their infection goes unrecorded.

Understanding the risks

There are 25 types of STI, four of which are incurable and eight of which have no symptoms. All of them are caught during unprotected sex with an infected partner, and because symptoms can often lie dormant, even partners who have been monogamous for a long time can suddenly discover an infection. The “big 5”, which most of us have heard of, are syphilis, gonorrhoea, genital herpes, genital warts and chlamydia. Most STIs, unlike HIVAids, are not life threatening, but untreated complications can be serious.

Syphilis is caused by bacteria. The initial signs - red painless spots in the genital area - can often go unnoticed, but in the secondary stage a red rash covers most of the body. Syphilis can usually be cleared with antibiotics, but left untreated can lead to infection of the central nervous system and of the heart.

Gonorrhoea is often painless for women, but men are likely to get pain while urinating and a white discharge. It can cause ectopic pregnancy and infertility, and although it is generally treatable with antibiotics, drug-resistant strains have recently begun to emerge.

Genital herpes is one of the incurables, but it can be kept under control by daily antiviral drugs. It shows up as small blisters and painful ulcers and sometimes flu-like symptoms. It can be spread from skin to skin as well as by oral contact, because the blisters carry the infection. Genital warts, too, can be found in the mouth as well as the genital areas. They are best treated by a chemical ointment or by freezing. Perhaps the most tricky STI to treat is chlamydia because in 70 per cent of infected women and half of infected men it is asymptomatic, that is, there are no obvious symptoms. Because of this, it can remain undiagnosed for a year or more, but long-term effects include pelvic inflammatory disease, ectopic pregnancy and infertility, and babies born to infected mothers are prone to pneumonia shortly after birth.

A thing of the past?

STIs have been a stubborn problem throughout history: 16th-century Europe suffered a plague of syphilis, and in the 19th century STIs accounted for more fatalities in the British armed forces than conflict. It was only with the mass-production of penicillin at the end of the 1940s that the infections became manageable. But while we might think of STIs as belonging to the age of VD (venereal disease), “the pox” (syphilis) and “the clap”

(gonorrhoea), they are probably as rife today as in 1430, when a survey of medieval London recorded incidences of infection in the brothels along the Thames. All kinds of myths persist about STIs. Can you catch them from toilet seats, or from sharing towels? (The answer is no.) And there is still a good deal of reticence around discussing STIs openly, and a lingering sense in some quarters that infection is a kind of punishment for promiscuity.

Why the increase?

There is no single explanation for the current growth in STI rates. Many doctors believe the rise in bacterial infections such as chlamydia reflects a general deterioration in the sexual health of young people, and it’s likely that a combination of factors is involved. Firstly, there has been a reduction in the age at which people first have sex. Latest figures from the National Survey of Sexual Attitudes and Lifestyles, published in 2001 and covering the decade from 1990, showed that 26 per cent of women and 30 per cent of men aged between 16 and 19 had had sex before they were 16. The younger people are when they first have sex, the less likely they are to use protection: research by Brook, a charity which works with young people on sexual health issues, has shown that 18 per cent of men and 22 per cent of women who had first intercourse at 13 or 14 used no contraception, compared to 8 per cent of men and 9 per cent of women who began having sex aged 16.

As well as having sex earlier, we are also having more partners, and increasing numbers of people are having more than one partner at a time.

This is particularly true of young people, with over 20 per cent of 15 to 24-year-old men and 15 per cent of young women admitting to concurrent sexual relationships.

As with teenage pregnancy rates, there are big variations in the incidence of STIs across the UK. Research has shown a direct correlation with social deprivation. Culture also plays a part; a study published in The Lancet in 2005 found people from Indian and Pakistani communities had the lowest levels of infection. How people choose sexual partners, their age and marriage patterns, the background level of untreated STI in different communities and the speed and completeness of treatment are all likely to be important.

The link with HIVAids

Another complication has been the impact of the HIVAids campaigns. When these were in full flow, during the early 1990s, other infections were often ignored. This can be a real problem for some of the parents of today’s at-risk teens. “Parents are often totally unaware that STIs exist,”

explains Dr Olwen Williams, consultant in genito-urinary medicine at Wrexham Maelor Hospital. “They were probably touched by the Aids campaign, but we weren’t talking about chlamydia then. So when their kids turn up at the clinic they’re horrified.”

But the reduction in money and attention given to HIVAids in more recent years has made the problem even worse. Traditional STIs are not seen as such a political priority, and awareness about sexual health risks has fallen disturbingly, especially among the young. A Health Committee report published in June 2003 found that three quarters of young people had never heard of chlamydia, while condom awareness is far lower than it was 10 years ago. And HIVAids and STIs are not only part of the same publicity conundrum. There is growing evidence that traditional STIs and HIV might feed off each other in more physical ways: those infected with a number of untreated STIs are more likely to also become infected with HIV.

The right to know

All schools must have a sex and relationships education (SRE) policy, but it isn’t compulsory to include STIs, only the biological basics about reproduction - and this is all some children get. Sometimes schools consciously choose not to cover STIs, perhaps for religious reasons. But a lack of adult knowledge can also be to blame, and not just on teachers’

part. “Governors tend not to have much time. And there’s often a huge gap when it comes to them knowing and understanding all the issues around SRE,”

says Anna Martinez, co-ordinator for the Sex Education Forum, a network of 47 organisations from sexual health groups to churches. To tackle this, the Forum has produced resources and training for governors, but there is still concern that until teaching about STIs is made compulsory, large numbers of children will be left without sufficient knowledge to protect themselves.

“Young people have a right to more than rudimentary biology,” says Ms Martinez. “The unequal access to information about STIs is a real concern.”

To tell or not to tell

Young people are entitled to confidential sexual health advice and treatment; though this was challenged, unsuccessfully, in the High Court last year in a high-profile case. Not surprisingly, it seems most young people would rather deal with itchy, painful or embarrassing infections without worrying about what the adults around them might think: in a survey published by Brook earlier this year, 74 per cent of under-16s said they would be less likely to seek advice on STIs if they thought teachers would pass on information about their sex lives.

But although the legal challenge to the principle of confidentiality failed, in practice, getting help can still mean pupils putting their heads above the parapet. Health experts report that teachers often feel obliged to notify senior staff if they know someone is having under-age sex or needing help with an STI. And accessing sexual health services outside school often means getting permission for absence or making special transport arrangements, particularly in rural areas. “There are all kinds of barriers,” says Dr Williams. For many teenagers, school-based services are often the easiest to get to, but Dr Williams suggests tackling STIs with a range of other health matters, from smoking and acne to diet. “This means someone can get help without identifying themselves to their peers and teachers as that sexually-active girl from Year 10.”

Just say no... or just say not yet?

While everyone recognises that the rise in STIs among young people is a serious problem, there is much less consensus about how to tackle the root causes. One approach is simply to persuade teenagers to stop having sex altogether. The youth abstinence movement in the United States, financed by the government to the tune of $270 million (pound;146 million), goes from strength to strength. About a third of US secondary schools now have abstinence programmes as their only form of sex education, and the message is being enthusiastically exported. Although the abstinence lobby is less powerful in the UK, conservative and religious groups are increasingly calling for schools to promote the abstinence alternative.

Another option, known as “abstinence plus”, concentrates on delaying, rather than forbidding, early sexual activity. The main difference is that young people are provided with safe-sex information so that they can look after their health when the time comes. One of the most successful abstinence plus programmes is APAUSE (Added Power and Understanding in Sex Education), developed by the University of Exeter. Working with over 100,000 young people in England and Wales, it uses Year 12 students as peer educators to get the message across. And the message is that later is often better.

“Many young people have serial relationships, which can be damaging to health. We want to help them delay sexual activity until they are ready and until they have really thought about it. It means they’re less likely to regret it,” explains Dr John Tripp, director of APAUSE.

“We’re not trying to reduce young people’s emancipation, but to help them grow up safely and enjoy long and more successful sexual relationships.”

Warts and all?

Supporters of comprehensive sex education believe the best way of improving rates of STI is to give young people all the facts they need, without loading them with pressures to stop or delay sex. In turn, this information can be used to develop more sophisticated life skills. “It’s not only about being fully informed about things such as STIs; it’s about giving young people the skills to put that knowledge into practice,” says Melissa Dear, of the fpa (family planning association). “It’s about raising self-esteem and improving communication skills so that young people are better able to negotiate their relationships.”

And the evidence seems to suggest that this kind of comprehensive approach works best. Studies of abstinence programmes have shown that although a virginity pledge delays the age at which young people first have sex by about 18 months, and reduces the number of sexual partners, pledgers are just as likely to contract an STI as someone who had been sexually active.

Why? Because they were much less likely to use condoms. While abstinence may work for those who live up to the ideal, those who fall off the wagon are left without the knowledge to protect themselves.

Studies of comprehensive programmes worldwide, however, suggest that warts-and-all sex education is the best way to reduce behaviour that puts young people at risk of STIs. There are exceptions: pro-abstinence groups picked up on research at the University of Nottingham in 2004, for example, which showed that in some areas with increased access to family planning services, teen STI rates had actually risen. But some of this rise was due to better screening and diagnosis and, perhaps unsurprisingly, the issue also seems to be about the quality of the information and the way it is delivered. The Nottingham research looked at NHS family planning clinics, largely doling out condoms, rather than broad sex education programmes based in schools. “We need participative, imaginative provision with highly trained staff,” says Melissa Dear. “We know a good programme can be effective in reducing infection rates. It’s iniquitous that this provision varies so widely.”

Resources

* Apause: tel, 01392 403146; www.programmes.ex.ac.ukapause.

* Avert is particularly focused on HIVAids but has plenty of resources on other STIs including statistics on rates worldwide: www.avert.org.uk.

* British Association for Sexual Health and HIV: tel, 020 7290 2968; www.bashh.org.

* Brook: tel, 0800 0185 023, free and confidential advice for under-25s; www.brook.org.uk.

* Fpa helplines: 0845 310 1334 (England and Wales); 0141 576 5088 (Scotland); www.fpa.org.uk.

* NHS Health Scotland (formerly the Health Education Board) has resources and information. Tel: 0131 536 5500; www.healthscotland.com.

* Marie Stopes International: tel, 0845 300 80 90; www.mariestopes.org.uk.

* www.playingsafely.co.uk is an excellent NHS sexual health website specifically aimed at young people.

* There is also a sexual health website for young people at www.likeitis.org.

* Sex Education Forum, part of the National Children’s Bureau, has details of campaigns and research as well as resources and publications. Tel 020 7843 1901; www.ncb.org.uksef.

* Sexual Health Line (0800 567 123) is a free and confidential 24-hour service.

* Sexwise: 0800 28 29 30, free and confidential for under 19s, seven days a week, 7am-midnight.

* Society of Sexual Health Advisers (SSHA). As well as being a professional body for those working in sexual health, the SSHA has information about infections and treatment. www.ssha.infopublic.

* Terrence Higgins Trust has lots of information about safer sex: tel, 0845 12 21 200; www.tht.org.uk.

* Details of the National Survey of Sexual Attitudes and Lifestyles can be downloaded from www.natcen.ac.uknatcenpagesfindastudy.htm.

Main text: Steven Hastings

Photographs: GettyScience Photo Librar yAdditional research: Sarah Jenkins

Next week: Gangs

The Issue

Did you know?

* More teenagers are having more sex, at a younger age, with more partners.

Research shows that 18 per cent of men and 22 per cent of women who had first intercourse at 13 or 14 used no contraception

* Someone is diagnosed with a sexually transmitted infection (STI) every 15 seconds. Cases of chlamydia - which often has no symptoms - have tripled since 1995, rising to 20,000 a year

* More than 50,000 16 to 19-year-olds visited a genito-urinary medicine (GUM) clinic in 2004; plenty more are too embarrassed to seek help

* There are 25 types of STI. Four are incurable; eight have no symptoms

* It is not compulsory for schools to include sexually transmitted infections in sex and relationships education

* The US government spends $270 million (pound;143 million) a year persuading teenagers not to have sex